Common U.S. Health Insurance Terms: Understanding American Healthcare Coverage

Many international students are surprised when they first receive a U.S. health insurance bill and might wonder: "Isn’t my insurance supposed to cover everything? Why do I still owe hundreds of dollars for a doctor's visit? Why do I need to pay upfront before the insurance reimburses me?" To clear things up, here’s a quick guide to health insurance terms you’ll likely see during or after a doctor’s visit. This will help you understand how insurance works so you can pick the best coverage for your needs.

Waiver：

If you're an international student on an F-1 visa and decide to go with your own health insurance instead of the school-sponsored plan, you’ll need to submit a Waiver. This simply shows that your chosen insurance meets the school’s requirements. Schools usually have specific coverage criteria, and the waiver is your way of proving that your plan meets these criteria.

Premium：

The premium is the amount you pay to keep your health insurance active. This can be paid monthly, quarterly, or annually, depending on your plan.

Deductible：

A deductible is the amount you need to pay before your insurance begins to cover. For example, if you have a $500 deductible, you’ll pay the first $500 in covered medical costs. Typically, lower deductibles mean higher premiums.

Copayment：

A copayment, or copay, is a fixed fee you pay each time you visit a doctor or pick up a prescription. It’s kind of like a registration fee you might see in some other countries. Copayment can vary depending on the type of service.

Coinsurance：

Once you’ve met your deductible, coinsurance is the percentage of each medical bill that you’re responsible for. For example, if you have an 80% coinsurance plan, your insurance will cover 80% of the bill, and you’ll be responsible for the remaining 20%.

Out-of-Pocket Maximum：

The out-of-pocket maximum is the maximum amount you’ll pay for covered services in a policy year. Once you reach this limit, your insurance covers 100% of your medical expenses for the rest of the policy year.

Maximum Benefit:

The maximum benefit is the total amount your insurance plan will pay for covered expenses. It is the highest amount your insurer will provide over the policy period.

In-Network Provider:

In-network providers are hospitals, doctors, and pharmacies that have contracts with your insurance company. Using these providers usually costs you less since they offer negotiated rates.

Out-of-Network Provider:

Out-of-Network Provider: Out-of-network providers don’t have contracts with your insurance company. Visiting these providers typically costs you higher copays, deductibles, and coinsurance.

Preventive Care:

Preventive care includes services like annual checkups and vaccines, which are often fully covered by insurance. Examples of preventive care include  annual physical exams, well-child visits, and well-woman exams.

Pre-existing Condition:

A pre-existing condition refers to any injury, illness, pain, or other medical, physical, psychological, or mental condition that existed before your insurance coverage started. This includes conditions you were and weren't aware of. Conditions that have never previously shown symptoms or been diagnosed can still be considered pre-existing if they emerge after your policy starts.

Waiting Period:

Some insurance policies require a waiting period before they cover certain diseases or conditions, typically ranging from six months to a year. During this period, you might not be able to file a claim. For instance, many dental insurances have waiting periods for procedures like extractions or root canals. If you have special medical needs, it's important to carefully read the terms regarding pre-existing conditions and their associated waiting periods to avoid issues during claims.

Preferred Provider Organization:

A Preferred Provider Organization, or PPO, is a type of health insurance that the company secures discounted medical service rates by negotiating with a network of healthcare providers. When you visit a provider within a PPO network, you receive care at a lower cost, and the insurance company pays a higher portion of the fees. The benefit of a PPO is that you don't need to have a primary care physician and can see specialists without a referral.

Prescription Drug/RX:

Prescription drugs are medications that can only be prescribed by doctors licensed in the United States. These drugs often have specific usage requirements and potential risks, and must be used under a doctor's supervision.

Primary Care Physician:

A Primary Care Physician, or PCP, is your first point of contact for non-urgent symptoms, general health inquiries, or routine check-ups, helping you navigate your health effectively. If you're unsure about a symptom, have a non-urgent health issue, or need a routine check-up, you should consult your PCP.

Explanation of Benefits:

After receiving medical services, you'll get an Explanation of Benefits (EOB) from your insurance. This document isn’t a bill but a summary that details how much the insurance paid and what portion you owe.

For international students looking for reliable health insurance, Tigerless Insurance offers plans using Aetna's PPO network, with various deductibles to fit different budgets. In addition, our F1 health insurance plan covers everything from vaccinations to emergency visits, making it a solid choice for those studying in the U.S. If you have questions or need help understanding your plan, our 24/7 customer service team is always ready to assist!